(Inter)National, Multicentred Appendicectomy Audit
Aneel BhanguGeneral Surgery Registrar
West Midlands Research Collaborative
1. First things first
•Why we did it•What we found•Future trials
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National Collaborative
• 3rd National meeting• National Research Collaborative• Simple, easy, accessible idea• “All” trainees and hospitals• Many questions
– Feasibility, Structure, Organisation
Aim
• Aim: a national (international), multicentred, audit of appendicectomy
• Primary outcome: negative rate• Secondary outcomes: laparoscopy rates,
adverse event rates• Inclusion: appendicectomy, all ages• Exclude: diagnostic lap
Method• Protocol – reviewed by Prof Alderson• 2 week 5 centre pilot in West Mids• 2 month multi-centred audit• 30 centres will recruit approximately 1000
patients – LSRG, WMRC, Mersey, EoE, Trent, Sparcs, PSTRN– Hong Kong, Aus, New Zealand
Scottish Surgical Registrars Research
Group
Newcastle Surgical Research Collaborative
General Surgical Research Collaboratives
Data collection• May 1st- June 30th, 30 day FU• Access Database with guidance notes• Strict confidentiality - only anonymised data
submitted via nhs.net• Audit registration• Centrally collated• Authorship model
To date
• Over 60 centres registered • 30 have confirmed via unit questionnaire or audit
registration form• 15*30 = 450 patients to date• Database
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Results
• 95 centres• 3326 patients• 89 UK centres• 6 international centres
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Results II
• (Initial) open appendicectomy: 33.7% (range 3.3-36.8% in centres>25 appendicectomies)
• Initial lap approach: 66.3% (8.7-100%)
• Lap conversion in 6.9% (of total)
• A consultant was present in theatre: 23.8% (1.9-84.6%)
• Histologically normal appendix: 20.6% (3.3-36.8%).
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What we did well
• Communication networks • Speed• Volume
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Where we could have improved
• Definitions and outcomes• Even wider communication • Data collection tools (teething problems only)
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Summary of aims
• Aim to perform a high quality, multi-centred audit• Aim to establish a national collaborative
research network• Build an RCT from this
Future trials
1. Lap v open appendicectomy
2. Lap normal appendix
3. Right iliac fossa pain of uncertain cause
4. Operative versus antibiotic treatment
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Lap normal appendix
• Rationale: no evidence to guide practice at present.
• What we can add: a multicenter trial
• Difficulties: – need to randomize everyone to capture target market.
Combining as an arm of another study is feasible, but will increase sample size significantly.
– Needs one year FU.
– Endpoint: Reducing LoS; readmissions; adverse events.
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lap v open appendicectomy
• Rationale: – 0-100% lap rate from 95 centres in the national audit
– Current 62 RCTs from a Cochrane review mostly single centre (only 3 were >3 centres)
– Mostly used length of stay as primary outcome
• What we can add: – a multicenter, national RCT with adverse events as an outcome.
– Could aim for 1000 patients which may help stablise use of lap rates in the UK and beyond.
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Difficulties
• High volume centres with lap pathways/ centres with high lap rates unlikely to participate, leaving medium size centres who currently have mixed rates.
• Learning curves for trainees.
• Need to convince the community of the need for another trial on this topic.
• This idea could be trimmed down to selected patients rather than all-comers (e.g. those with risk factors for post-op adverse events)
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RIF pain of uncertain cause
• Rationale: management of undifferentiated RIF pain (and undifferentiated acute abdominal pain) is very topical and very under-researched.
• Design: Early diagnostic lap v imaging and observation. – May be best in females or reproductive age alone.
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• What we can add: a multicenter trial – only around 2 small RCTs currently done on this topic (but this proves feasibility). Could randomize the imaging/observation arm too.
• Difficulties: – Units would need to ensure pathways to access theatre and
imaging within 24 hours.
– surgeons may be reluctant to randomize?
– Potentially slow recruitment?
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operative versus antibiotic treatment of appendicitis
• Rationale: recent interest and meta-analysis of this as a future treatment. Meta-analysis showed 80% avoid appendicectomy by 12 months.
• What we can add: – no RCT has been done in the UK.
– Nigel Hall is planning to start a feasibility study in paediatric patients, to test whether randomization in the UK climate is feasible.
• Difficulties: high quality meta-analysis has showed outcomes (but not in UK). Will UK surgeons accept this?
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• Questions and discussion
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